Poverty, food programs, and childhood obesity

Household food insecurity and childhood obesity/overweight among children with special healthcare needs: Results from a nationally representative sample of 10-17 years old U.S. children

BACKGROUND

Food insecurity is linked to an increased risk of childhood obesity and other adverse health issues.

OBJECTIVES

To examine the disproportionate impact of food insecurity on childhood obesity among children with special healthcare needs (CSHCN).

METHODS

In this cross-sectional study, we pooled data from 4 years (2016 to 2019) of the National Survey of Children's Health (NSCH) for a nationally representative sample of 10 to 17 years old noninstitutionalized U.S. children (N = 68 942). Using logistic regression models, we examined the odds of childhood obesity or overweight by including an interaction between family food situation and CSHCN status.

RESULTS

Among 10-17 years old U.S. children, 31% (95% confidence interval [CI]: 30.1%-31.9%) had obesity or overweight, 24.1% had special healthcare needs, 27.2% were from families with food insecurity, and 6.4% were from families with food insufficiency. CSHCN were more likely to be impacted by obesity or overweight than non-CSHCN (Odds Ratio [OR] = 1.29, 95% CI = 1.18-1.141). Moreover, children living in food insecurity (OR = 1.75, 95% CI = 1.52-1.92) and food insufficiency (OR = 2, 95% CI = 1.67-2.4) were more likely than those living in food-secure families to be impacted by obesity or overweight. CSHCN living in food insecurity were significantly more likely to be impacted by obesity or overweight than non-CSHCN in similar households.

CONCLUSIONS

It appears that food insecurity can put CSHCN at disproportionately greater risk of obesity or overweight than non-CSHCN. The findings underscore considering CSHCN status in conjunction with household food insecurity in designing and implementing medical interventions or public policies targeted at childhood obesity or overweight.

The Relationship between School Infrastructure and School Nutrition Program Participation and Policies in New York City

School nutrition programs (SNP) provide much needed access to fruits, vegetables, and other healthy foods at low or no cost. Yet, the infrastructure of school kitchens and cafeteria vary across schools, potentially contributing to systematic barriers for SNP operation and equity. The purpose of this paper is to examine the association between school infrastructure and outcomes including meal participation, untraditional lunch periods, and having an open campus. Regression analyses were conducted using administrative data for 1804 schools and school nutrition manager survey data (n = 821) in New York City (NYC). Co-location was significantly associated with open campus status (OR = 2.84, CI: 1.11, 7.26) and high school breakfast participation (β = -0.056, p = 0.003). Overcrowding was associated with breakfast (elementary: β = -0.046, p = 0.03; middle: β = 0.051, p = 0.04; high: β = 0.042, p = 0.04) and lunch participation (elementary: β = -0.031, p = 0.01) and untraditional lunchtimes (elementary: OR = 2.47, CI: 1.05, 5.83). Higher enrollment to cafeteria capacity ratios was associated with breakfast (elementary: β = -0.025, p = 0.02) and lunch (elementary: β = -0.015, p = 0.001; high: β = 0.014, p = 0.02) participation and untraditional lunchtimes (middle: OR = 1.66, CI: 1.03, 2.68). Infrastructure characteristics are an important source of variation across NYC schools that may hinder the equity of school nutrition programs across the city.

Do additional SNAP benefits matter for child weight?: Evidence from the 2009 benefit increase

We know that youth who live in low-income households tend to have lower nutritional health outcomes-including higher rates of obesity-when compared to their higher-income counterparts. The Supplemental Nutrition Assistance Program (SNAP) is the largest U.S. federal nutrition program and has been found to improve food security and to serve as an income support. It is less clear how SNAP may affect obesity in low-income youth. From a policy perspective, it is essential to understand how the largest federal nutrition assistance program influences the health of children and adolescents. We use the exogenous increase in SNAP benefits that was a part of the American Recovery and Reinvestment Act (ARRA) to identify how a change in benefits is linked with obesity in youth. We find evidence that the ARRA increase in SNAP benefits is associated with healthier weight outcomes in three of the four age groups examined. SNAP-eligible toddlers are less likely to be overweight and adolescents are less likely to be obese. These findings can help policy makers understand how additional SNAP benefits from the Families First Coronavirus Response Act may influence weight outcomes in children and adolescents.

Use of Machine Learning to Determine the Information Value of a BMI Screening Program

INTRODUCTION

Childhood obesity continues to be a significant public health issue in the U.S. and is associated with short- and long-term adverse health outcomes. A number of states have implemented school-based BMI screening programs. However, these programs have been criticized for not being effective in improving students' BMI or reducing childhood obesity. One potential benefit, however, of screening programs is the identification of younger children at risk of obesity as they age.

METHODS

This study used a unique panel data set from the BMI screening program for public school children in the state of Arkansas collected from 2003 to 2004 through the 2018-2019 academic years and analyzed in 2020. Machine learning algorithms were applied to understand the informational value of BMI screening. Specifically, this study evaluated the importance of BMI information during kindergarten to the accurate prediction of childhood obesity by the 4th grade.

RESULTS

Kindergarten BMI z-score is the most important predictor of obesity by the 4th grade and is much more important to prediction than sociodemographic and socioeconomic variables that would otherwise be available to policymakers in the absence of the screening program. Including the kindergarten BMI z-score of students in the model meaningfully increases the accuracy of the prediction.

CONCLUSIONS

Data from the Arkansas BMI screening program greatly improve the ability to identify children at greatest risk of future obesity to the extent that better prediction can be translated into more effective policy and better health outcomes. This is a heretofore unexamined benefit of school-based BMI screening.

Food insecurity and obesity: research gaps, opportunities, and challenges

Food insecurity, defined as a lack of consistent access to enough food for an active, healthy life, is a major public health concern with 11.8% of U.S. households (15.0 million) estimated to be affected at some point in 2017 according to the United States Department of Agriculture Economic Research Service. While the link between food insecurity, diet quality, and obesity is well documented in the literature, additional research and policy considerations are needed to better understand underlying mechanisms, associated risks, and effective strategies to mitigate the adverse impact of obesity related food insecurity on health. With its Strategic Plan for NIH Obesity Research, the NIH has invested in a broad spectrum of obesity research over the past 10 years to understand the multifaceted factors that contribute to the disease. The issue of food insecurity, obesity and nutrition is cross-cutting and relates to many activities and research priorities of the institutes and centers within the NIH. Several research gaps exist, including the mechanisms and pathways that underscore the complex relationship between food insecurity, diet, and weight outcomes, the impacts on pregnant and lactating women, children, and other vulnerable populations, its cumulative impact over the life course, and the development of effective multi-level intervention strategies to address this critical social determinant of health. Challenges and barriers such as the episodic nature of food insecurity and the inconsistencies of how food insecurity is measured in different studies also remain. Overall, food insecurity research aligns with the upcoming release of the Strategic Plan for NIH Nutrition Research and will continue to be prioritized in order to enhance health, lengthen life, reduce illness and disability and health disparities.

Protecting children's health in a calorie-surplus context: Household structure and child growth in the United States

Studies from the social and health sciences have tended to view the household as the locus of access to and distribution of care, resources, monitoring and modeling for children's wellbeing. Obesity may present a special case for the study of investments in children, being a component of health for which more of certain inputs may not lead to better outcomes. We expanded on common measures of household structure in the child health literature by considering co-residence and relatedness of parents, grandparents, other relatives, and other children. Data were from a longitudinal sample of 6,700 children participating in the Early Childhood Longitudinal Study Kindergarten Class of 1998-99 (ECLS-K), the largest U.S. national dataset with measures of child anthropometrics and household structure at seven time-points over nine years. We used lagged survey-adjusted regressions to estimate associations between household structure and subsequent changes in children's weight between ages 5 and 14 years in terms of BMI gain and incident obesity. Adjusting for household structure more thoroughly, children living in households with two parents rather than one parent did not experience advantages in terms of less excess weight gain or lower incidence of obesity during elementary and middle school. Children living with a grandmother gained more weight than children not living with a grandmother. Living with siblings and with non-related adults was associated with less weight gain. These findings corroborate a scenario in which, for health problems associated with caloric surplus, classic household factors have more complex associations with child wellbeing.

The Supplemental Nutrition Assistance Program and Child Weight Status: A Review

CONTEXT

The Supplemental Nutrition Assistance Program (SNAP) is a food assistance program that helps Americans afford a healthy diet. However, its influence on children's weight status is unclear. This review examined the evidence of the relationship between SNAP participation and child weight.

EVIDENCE ACQUISITION

The following databases were searched: PubMed, EconLit, Web of Science, and the U.S. Department of Agriculture Economic Research Service. The last search was performed in October 2018. This systematic review gives a narrative synthesis of included studies.

EVIDENCE SYNTHESIS

Twenty-three studies that examined the weight outcomes of children aged 2-18 years and SNAP participation were included. Eleven studies found no significant relationship between SNAP and child weight outcomes. Nine found that SNAP participation was associated with increased weight outcomes in certain subpopulations, and four found that SNAP was linked to a predicted decrease in weight outcomes in some subpopulations. However, many of these studies did not address a key methodologic challenge: self-selection. Of those that did, five found that SNAP participation was associated with an increased risk of being overweight and elevated weight in certain subpopulations.

CONCLUSIONS

SNAP participation may help boys maintain a healthy body weight but can be a contributing factor in being overweight or obese in girls who are long-term participants, or who are already overweight. Food security and participation in multiple food assistance programs may be important modifiers. These findings are relevant to policymakers who are considering reducing SNAP funding or restructuring the program. Further research that utilizes strong designs is needed.

Association between socioeconomic status and obesity among 12-year-old Malaysian adolescents

The epidemic of obesity in developed countries is commonly associated with poor dietary habit and sedentary lifestyle. However, other determinants, including education background and family income, may contribute towards the problem especially in developing countries. This study aimed to determine the influence of socioeconomic status (SES) on obesity among 12-year-old school adolescents in Terengganu, Malaysia. Body weight and height were measured and BMI was categorised based on WHO z-score cut-off points. Information was obtained from self-reported questionnaire on parents' education background, family income and occupation. A total of 3,798 school adolescents aged 12 years (44% boys and 56% girls) were recruited. There was no significant difference in BMI status between boys and girls, or between rural and urban participants. There were significant differences between BMI categories and gender, household income and SES level within rural areas. In the urban areas, significant differences were found between BMI categories and gender, parents' occupational and educational level, household income and size, and SES level. A logistic regression model found several SES factors to be predictors of obesity in this population, namely, gender, household size, father's occupation level, household income level and SES level. Each component of SES has been significantly associated with the BMI category of school adolescents, particularly in the urban areas. This suggests the requirement of multifaceted approaches, including the role of family, society and authorities, in the effort to curtail adolescent obesity.

Maternal and familial correlates of anthropometric typologies in the nutrition transition of Colombia, 2000-2010

OBJECTIVE

We aimed to assess the maternal and family determinants of four anthropometric typologies at the household level in Colombia for the years 2000, 2005 and 2010.

DESIGN

We classified children 2) to assess stunting and overweight/obesity, respectively; mothers were categorized according to BMI to assess underweight (<18·5 kg/m2) and overweight/obesity (≥25·0 kg/m2). At the household level, we established four final anthropometric typologies: normal, underweight, overweight and dual-burden households. Separate polytomous logistic regression models for each of the surveyed years were developed to examine several maternal and familial determinants of the different anthropometric typologies.

SETTING

National and sub-regional (urban and rural) representative samples from Colombia, South America.

SUBJECTS

Drawing on data from three waves of Colombia's Demographic and Health Survey/Encuesta Nacional de Salud (DHS/ENDS), we examined individual and household information from mothers (18-49 years) and their children (birth-5 years).

RESULTS

Higher parity was associated with an increased likelihood of overweight and dual burden. Higher levels of maternal education were correlated with lower prevalence of overweight, underweight and dual burden of malnutrition in all data collection waves. In 2010, participation in nutrition programmes for children <5 years, being an indigenous household, food purchase decisions by the mother and food security classification were also associated with the four anthropometric typologies.

CONCLUSIONS

Results suggest that maternal and family correlates of certain anthropometric typologies at the household level may be used to better frame policies aimed at improving social conditions and nutrition outcomes.

High School Physical Education Requirements and Youth Body Weight: New Evidence from the YRBS

Previous research has found that high school physical education (PE) requirements are largely ineffective at reducing youth body weight. However, these studies were forced to rely on cross-state variation in PE requirements to identify their impacts, raising concerns that estimated policy effects may be confounded by state-level unobservables. Using data from the State and National Youth Risk Behavior Surveys and exploiting recent changes in state high school PE laws, we re-examine the effect of PE requirements on body weight. Our estimates show that a one-semester increase in PE requirements is associated with a 10 to 13% increase in minutes per week spent physically active in PE classes, but with no change in net vigorous exercise and little change in youth body weight. We conclude that substitution of in-school for outside-of-school physical activity and small resultant net energy expenditures can explain the absence of body weight effects. Copyright © 2016 John Wiley & Sons, Ltd.

[Obesity risk in preschoolers beneficiaries of food aid programs]

Objective To review the evidence regarding the potential impact of food programs on the risk of obesity in beneficiary children. Methods The search was conducted in databases using terms in Spanish and English. Those items that included the variable of interest, cross sectional studies, cohort or community trials were selected. Results Food assistance programs could contribute to increased obesity rates in the target population due to the availability and easier access to food with high energy content, either through the delivery of provisions or cash. However, the impact of the programs on this outcome has been little studied and evaluations have been mostly in adults or school-age children. Conclusion This review contributes to knowledge about the possible effect that food programs have on the risk of obesity in beneficiary children. This review may also serve as a reference for the design, implementation and evaluation of food and nutrition programs in countries of low and middle income facing malnutrition.

SNAP Participation and Diet-Sensitive Cardiometabolic Risk Factors in Adolescents

INTRODUCTION

Previous research suggests participation in the Supplemental Nutrition Assistance Program (SNAP) is associated with poorer adult cardiometabolic health; the extent to which these associations extend to adolescents is unknown. Differences in diet quality, obesity, and cardiometabolic risk factors were examined among SNAP participants, income-eligible nonparticipants, and higher-income adolescents.

METHODS

The study population comprised 4,450 adolescents ≤300% federal poverty level from the 2003-2010 National Health and Nutrition Examination Survey. Generalized linear models were used to examine associations between SNAP participation and the Alternate Healthy Eating Index-2010. Linear and logistic regression models were used to examine associations between SNAP participation, obesity, and risk factors comprising the metabolic syndrome. Data were analyzed in 2015.

RESULTS

All surveyed adolescents consumed inadequate amounts of vegetables, fruits, whole grains, and long-chain fatty acids, while exceeding limits for sugary beverages, processed meats, and sodium. Although there were few dietary differences, SNAP participants had 5% lower Alternate Healthy Eating Index-2010 scores versus income-eligible nonparticipants (95% CI=-9%, -1%). SNAP participants also had higher BMI-for-age Z scores (β=0.21, 95% CI=0.01, 0.41), waist circumference Z scores (β=0.21, 95% CI=0.03, 0.39), and waist-to-height ratios (β=0.02, 95% CI=0.00, 0.03) than higher-income nonparticipants. SNAP participation was not associated with most cardiometabolic risk factors; however, SNAP participants did have higher overall cardiometabolic risk Z scores than higher-income nonparticipants (β=0.75, 95% CI=0.02, 1.49) and income-eligible nonparticipants (β=0.55, 95% CI=0.03, 1.08).

CONCLUSIONS

Adolescent SNAP participants have higher levels of obesity, and some poorer markers of cardiometabolic health compared with their low-income and higher-income counterparts.

Obesity and Poverty: Are Food Stamps to Blame?

Sixty-six percent of adults in the United States are overweight, and 32% of Americans are obese. Although poverty is usually associated with being underfed and underweight, in the United States, the paradoxical relationship between poverty and overweight exists. This article examines the relationship between Food Stamp Program (FSP) participation, food choices, and overweight status. This article examines the practicality of an individual in New York adhering to U.S. Department of Agriculture (USDA) recommendations for a diet rich in whole grains, lean meats, fruits, and vegetables on a FSP budget. The authors concluded that a diet that consists of more processed, high-calorie foods is significantly more agreeable with a FSP budget than a diet that meets USDA recommendations.

Deconstructing race and gender differences in adolescent obesity: Oaxaca-blinder decomposition

OBJECTIVE

To analyze sources of racial and gender disparities in adolescent obesity prevalence in the United States using Oaxaca-Blinder decomposition.

METHODS

Data were obtained from the National Youth Physical Activity and Nutrition Study, a 2010 nationally representative study of 9th-12th grade students. Obesity status was determined from objective height and weight data; weight-related behaviors and school, home, and environmental data were collected via questionnaire. Oaxaca-Blinder decomposition was used to independently analyze racial and gender obesity prevalence differences (PD), i.e., comparing Black girls to White girls, and Black girls to Black boys.

RESULTS

Overall, measured characteristics accounted for 46.8% of the racial PD but only 11.9% of the gender PD. Racial PD was associated with Black girls having less fruit/vegetable access at home, obtaining lunch at school more often, and playing fewer sports than White girls. Gender PD was associated with differential associations between physical activity (PA) measures-including total activities in the past year and days of moderate to vigorous physical activity (MVPA) in the past week-and obesity.

CONCLUSIONS

School lunch and home food environmental variables accounted for racial disparities, but not gender disparities, in obesity prevalence. Gender differences in mechanisms between PA and obesity should be explored further.

Federal Food Assistance Programs and Cardiovascular Risk Factors in Low-Income Preschool Children

Childhood obesity remains a significant public health concern. Children from lower income households have a greater risk of being obese. Low-income families generally have less access to healthy, affordable food choices and turn to federal food assistance programs. Few studies have examined the impact of food assistance programs on childhood obesity rates. This study explored the association between BMI, blood lipid levels, and three food assistance programs (WIC, reduced lunch, and food stamps) in a sample of predominantly low-income, minority preschool children enrolled in a city-wide preschool program. Screenings were performed at on-site health fairs conducted at nine schools in disadvantaged areas. Screenings included vital signs, a finger stick, head-to-toe exam, vision screening, dental screening, and hearing screening. Of the sample of 229 preschool children, 23.1 % were obese, almost three times the national rate in preschoolers. Children whose families received WIC benefits weighed significantly less than those who did not receive benefits. In addition, 20.6 % of the children screened had elevated systolic blood pressures. Of the sample, 33 % had unhealthy triglyceride levels and 46 % had unhealthy HDL levels with those that received WIC benefits having significantly lower levels of LDL cholesterol This study confirms that low-income, minority children in the South continue to be disproportionately affected by overweight and obesity. In addition, the results of this study indicate WIC as a potential public health initiative to combat the childhood obesity epidemic and reduce other cardiovascular risk factors, such as blood lipids and blood pressure.

A Historical Review of Changes in Nutrition Standards of USDA Child Meal Programs Relative to Research Findings on the Nutritional Adequacy of Program Meals and the Diet and Nutritional Health of Participants: Implications for Future Research and the Summer Food Service Program

Background: The USDA child meal programs (CMPs) (National School Lunch Program (NSLP), School Breakfast Program (SBP), and Summer Food Service Program (SFSP) were established in 1946 (NSLP) and 1975 (SBP and SFSP) to improve the diet and nutritional health of US children. There is concern that participation in these programs may in fact be a contributor to the current childhood obesity epidemic. Objective: The purpose of this study was to determine if the CMPs are meeting their intended goal by reviewing the historical changes to nutrition standards of the CMPs in correspondence with the literature that examines the nutritional adequacy of meals served as part of these programs, as well as the dietary intakes and nutritional status of participants. Methods: Public Law and the Federal Register were reviewed and websites and online databases were systematically searched. Results: NSLP and SBP first underwent updates to the nutrition standards in 1994 and subsequently 2010, whereas SFSP last underwent modifications in 2000. The majority of data, all collected prior to 2010, demonstrate that meals served as part of the NSLP and SBP are not meeting nutrition standards. In addition, the dietary intakes of NSLP and SBP participants are high in calories, fat, saturated fat, and sodium, and low in fiber. Studies examining the weight status and other nutrition-related health outcomes of NSLP and SBP participants have produced mixed results. In contrast, no studies published in the peer-reviewed literature have been conducted examining the nutritional adequacy of SFSP meals or the dietary intakes or nutritional health of SFSP participants. There are public reports available on the nutritionally adequacy of SFSP meals, however, they are severely outdated (1988 and 2003). Due to this dearth of information, a case study on a sample SFSP menu from summer 2015 was conducted; results showed that the meals are high in carbohydrate and protein content and insufficient in vegetable servings. Conclusions: There is critical need for policy change that would enable updates to the SFSP nutrition standards to match those of the NSLP and SBP. In addition, strategies are needed to facilitate development of CMP menus that meet current nutrition standards. Finally, rigorously designed studies are needed to understand the direct impact of CMP participation on child diet and health, particularly the SFSP for which there is limited published data.

Socioeconomic position and childhood-adolescent weight status in rich countries: a systematic review, 1990-2013

Background

Childhood obesity is a major problem in rich countries due to its high prevalence and its harmful health consequences. An exploratory analysis conducted in the PubMed database highlighted that the number of papers published on the relationship between socioeconomic position (SEP) and childhood-adolescent weight status had risen substantially with respect to an earlier review which had covered the period 1990–2005.

Methods

To describe the findings on the relationship between SEP and childhood-adolescent weight status in papers published in rich countries from 1990 through 2013, studies were identified in the following databases: PubMed; Web of Knowledge (WOK); PsycINFO; Global Health; and Embase. We included observational studies from the 27 richest OECD countries, which covered study populations aged 0 to 21 years, and used parental education, income and/or occupation as family SEP indicators. A total of 158 papers met the inclusion criteria and reported 134 bivariable and 90 multivariable analyses.

Results

Examination of the results yielded by the bivariable analyses showed that 60.4 % of studies found an inverse relationship, 18.7 % of studies did not found relationship, and 20.9 % of studies found a relationship that varied depending on another variable, such as age, sex or ethnic group; the corresponding percentages in the multivariable analyses were 51.1, 20.0 and 27.8 %, respectively. Furthermore, 1.1 % found a positive relationship.

Conclusion

The relationship between SEP and childhood-adolescent weight status in rich countries is predominantly inverse and the positive relationship almost has disappeared. The SEP indicator that yields the highest proportion of inverse relationships is parents’ education. The proportion of inverse relationships is higher when the weight status is reported by parents instead using objective measurements.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-015-0443-3) contains supplementary material, which is available to authorized users.

Investigating the historic long-term population health impact of the US National School Lunch Program

OBJECTIVE

The present research aimed to compare historic participation in the US National School Lunch Program (NSLP) during childhood and subsequent prevalence of overweight and obesity among adults at the population level.

DESIGN

Regression models examined cross-sectional, state- and age-based panel data constructed from multiple sources, including the Behavioural Risk Factor Surveillance System, US Congressional Record, US Census and the US Department of Agriculture. Models controlled for cohorts' racial/ethnic composition and state poverty rates.

SUBJECTS

Adult-age cohorts (18-34, 35-49, 50-64 and 18-64 years) by US state over a 25-year period (1984-2008).

SETTING

The cohorts' prevalence of overweight and obesity was compared with the cohorts' estimated NSLP participation during schooling (1925-2007; the NSLP began in 1946).

RESULTS

Among adults aged 18-64 years, a one percentage-point increase in estimated NSLP participation during schooling between 1925 and 2007 was significantly associated with a 0·29 percentage-point increase in the cohort's later prevalence of overweight and obesity. Analysis of narrower age cohorts and different schooling periods produced mixed results.

CONCLUSIONS

The NSLP might have influenced population health historically. Longitudinal analysis of individuals from studies now underway will likely facilitate more robust conclusions about the NSLP's long-term health impact based on more recent experiences.

Misclassification of fourth-grade children's participation in school-provided meals based on parental responses relative to administrative daily records

Although many studies have relied on parental responses concerning children's school-meal participation, few studies have evaluated parental response accuracy. We investigated misclassification of fourth-grade children's participation in school-meal programs based on parental responses relative to administrative daily records using cross-sectional study data collected for 3 school years (2004-05, 2005-06, and 2006-07) for 1,100 fourth-grade children (87% black; 52% girls) from 18 schools total in one district. Parents reported children's usual school-meal participation on paper consent forms. The district provided administrative daily records of individual children's school-meal participation. Researchers measured children's weight and height. "Usual participation" in breakfast/lunch was defined as ≥50% of days. Parental responses misclassified 16.3%, 12.8%, 19.8%, and 4.7% of children for participation in breakfast, classroom breakfast, cafeteria breakfast, and lunch, respectively. Parental responses misclassified more children for participation in cafeteria than classroom breakfast (P=0.0008); usual-participant misclassification probabilities were less than nonusual-participant misclassification probabilities for classroom breakfast, cafeteria breakfast, and lunch (P<0.0001 for each) (two-proportion z tests). Parental responses concerning children's participation were more accurate for lunch than breakfast; parents overstated breakfast participation (both classroom and cafeteria) and lunch participation. Breakfast participation misclassification was not related to body mass index (P=0.41), sex (P=0.40), age (P=0.63), or socioeconomic status (P=0.21) (multicategory logistic regression controlling for school year, breakfast location, and school). Relying on parental responses concerning children's school-meal participation may hamper researchers' abilities to detect relationships that have policy implications for the child nutrition community. The use of administrative daily records of children's school-meal participation is recommended.

Food insecurity, food assistance and weight status in US youth: new evidence from NHANES 2007-08

OBJECTIVE

To investigate food assistance participation as a risk factor for overweight and obesity in youth, and food insecurity as an effect modifier.

METHODS

The sample included youth ages 4-17, in families ≤200% of the federal poverty line in the 2007-2008 National Health and Nutrition Examination Survey (n = 1321). Food insecurity was measured with the US Department of Agriculture survey module. Food assistance participation was assessed for Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants and Children and school meals. Body size was classified by age- and sex-specific body mass index (BMI) percentile, BMI z-score and waist circumference percentile. Regression models with direct covariate adjustment and programme-specific propensity scores, stratified by food insecurity, estimated associations between food assistance participation and body size.

RESULTS

Food assistance participation was not associated with increased body size among food-insecure youth in models with direct covariate adjustment or propensity scores. Compared with low-income, food-secure youth not participating in food assistance, BMI z-scores were higher among participants in models with direct covariate adjustment (0.27-0.38 SD and 0.41-0.47 SD, for boys and girls, respectively). Using propensity scores, results were similar for boys, but less so for girls.

CONCLUSIONS

Food assistance programme participation is associated with increased body size in food-secure youth, but not food-insecure youth. Using both direct covariate adjustment and a propensity score approach, self-selection bias may explain some, but not all, of the associations. Providing healthy food assistance that improves diet quality without contributing to excessive intake remains an important public health goal.

Economic Differences in Risk Factors for Obesity Among Overweight and Obese Children

The purpose of the study was to identify the economic differences in familial, physiological, psychological, and lifestyle characteristics associated with overweight and obese children in South Korea. A total of 407 overweight and obese children participated in the study. The obesity rate was 69.0% and the prevalence of metabolic syndrome (MS) was 33.3% in the low-income bracket, and the prevalence of MS was 27.2% for the population. The children in the low-income group were more prone to have poor eating behavior and more likely to spend more than 2 hr viewing television. They also were more likely to have lower self-esteem and more depressive symptoms. School nurses should understand that risk factors for childhood obesity are more prevalent in low-income groups, which will eventually aggravate health disparities between socioeconomic status groups. Therefore, prevention programs for childhood obesity, which target high-risk groups of such children need to be developed and prioritized.

Parent-reported height and weight as sources of bias in survey estimates of childhood obesity

Parental reporting of height and weight was evaluated for US children aged 2-13 years. The prevalence of obesity (defined as a body mass index value (calculated as weight (kg)/height (m)(2)) in the 95th percentile or higher) and its height and weight components were compared in child supplements of 2 nationally representative surveys: the 1996-2008 Children of the National Longitudinal Survey of Youth 1979 Cohort (NLSY79-Child) and the 1997 Child Development Supplement of the Panel Study of Income Dynamics (PSID-CDS). Sociodemographic differences in parent reporting error were analyzed. Error was largest for children aged 2-5 years. Underreporting of height, not overreporting of weight, generated a strong upward bias in obesity prevalence at those ages. Frequencies of parent-reported heights below the Centers for Disease Control and Prevention's (Atlanta, Georgia) first percentile were implausibly high at 16.5% (95% confidence interval (CI): 14.3, 19.0) in the NLSY79-Child and 20.6% (95% CI: 16.0, 26.3) in the PSID-CDS. They were highest among low-income children at 33.2% (95% CI: 22.4, 46.1) in the PSID-CDS and 26.2% (95% CI: 20.2, 33.2) in the NLSY79-Child. Bias in the reporting of obesity decreased with children's age and reversed direction at ages 12-13 years. Underreporting of weight increased with age, and underreporting of height decreased with age. We recommend caution to researchers who use parent-reported heights, especially for very young children, and offer practical solutions for survey data collection and research on child obesity.

Association between state laws governing school meal nutrition content and student weight status: implications for new USDA school meal standards

IMPORTANCE

This study assessed whether stronger school meal nutrition standards may improve student weight status. Results have immediate implications because of the ongoing implementation of new nutrition standards for the National School Lunch Program. OBJECTIVE To determine if state laws with stricter school meal nutrition standards are inversely associated with adolescent weight status, while controlling for unmeasured state-level confounders.

DESIGN

Quasi-experiment.

SETTING

Public schools.

PARTICIPANTS

Four thousand eight hundred seventy eighth-grade students in 40 states. Students were categorized by type of school lunch they usually obtained (free/reduced price, regular price, or none). INTERVENTIONS State laws governing school meal nutrition standards. States with standards that exceeded US Department of Agriculture (USDA) school meal standards were compared with states that did not exceed USDA standards. The parameter of interest was the interaction between state laws and student lunch participant status, ie, whether disparities in weight status between school lunch participants and nonparticipants were smaller in states with stricter standards.

MAIN OUTCOME MEASURES

Body mass index percentile and obesity status.

RESULTS

In states that exceeded USDA standards, the difference in obesity prevalence between students who obtained free/reduced-price lunches and students who did not obtain school lunches was 12.3 percentage points smaller (95% CI, -21.5 to -3.0) compared with states that did not exceed USDA standards. Likewise, differences in mean body mass index percentile between those student populations were 11 units smaller in states that exceeded USDA standards (95% CI, -17.7 to -4.3). There was little evidence that students compensated for school meal laws by purchasing more sweets, salty snacks, or sugar-sweetened beverages from other school venues (eg, vending machines) or other sources (eg, fast food).

CONCLUSIONS AND RELEVANCE

Stringent school meal standards that reflect the latest nutrition science may improve weight status among school lunch participants, particularly those eligible for free/reduced-price lunches.

Explaining the positive relationship between fourth-grade children's body mass index and energy intake at school-provided meals (breakfast and lunch)

BACKGROUND

A 2010 publication showed a positive relationship between children's body mass index (BMI) and energy intake at school-provided meals (as assessed by direct meal observations). To help explain that relationship, we investigated 7 outcome variables concerning aspects of school-provided meals: energy content of items selected, number of meal components selected, number of meal components eaten, amounts eaten of standardized school-meal portions, energy intake from flavored milk, energy intake received in trades, and energy content given in trades.

METHODS

Fourth-grade children (N = 465) from Columbia, SC, were observed eating school-provided breakfast and lunch on 1 to 4 days per child. Researchers measured children's weight and height. For daily values at school meals, a generalized linear model was fit with BMI (dependent variable) and the 7 outcome variables, sex, and age (independent variables).

RESULTS

BMI was positively related to amounts eaten of standardized school-meal portions (p < .0001) and increased 8.45 kg/m(2) per serving, controlling for other variables in the model. BMI was positively related to energy intake from flavored milk (p = .0041) and increased 0.347 kg/m(2) for every 100 kcal consumed. BMI was negatively related to energy intake received in trades (p = .0003) and decreased 0.468 kg/m(2) for every 100 kcal received. BMI was not significantly related to 4 outcome variables.

CONCLUSIONS

Knowing that relationships between BMI and actual consumption, not selection, at school-provided meals explained the (previously found) positive relationship between BMI and energy intake at school-provided meals is helpful for school-based obesity interventions.

Food purchasing selection among low-income, Spanish-speaking Latinos

BACKGROUND

In the U.S., poverty has been linked to both obesity and disease burden. Latinos in the U.S. are disproportionately affected by poverty, and over the past 10 years, the percentage of overweight U.S. Latino youth has approximately doubled. Buying low-cost food that is calorie-dense and filling has been linked to obesity. Low-income individuals tend to favor energy-dense foods because of their low cost, and economic decisions made during food purchasing have physiologic repercussions. Diets based on energy-dense foods tend to be high in processed staples, such as refined grains, added sugars, and added fats. These diets have been linked to a higher risk of obesity, type 2 diabetes, and cardiovascular disease.

PURPOSE

This pilot study conducted ethnographic qualitative analyses combined with quantitative analyses to understand grocery shopping practices among 20 Spanish-speaking, low-income Latino families. The purpose was to analyze food selection practices in order to determine the effect of nutrition education on changes in shopping practices to later develop educational tools to promote selection of healthier food options.

METHODS

Participants received tailored, interactive, nutrition education during three to five home visits and a supermarket tour. Grocery store receipts for grocery purchases collected at baseline and at the end of the project were analyzed for each family to extract nutritional content of purchased foods. Nutritional content was measured with these factors in mind: quantity, calories, fats, carbohydrates, fiber, protein, and percentage of sugary beverages and processed food. Data were collected in 2010-2011 and analyzed in 2011-2012.

RESULTS

After receiving between three and five home-based nutrition education sessions and a supermarket tour over a 6-month period, many families adopted instructions on buying budget-friendly, healthier alternative foods. Findings indicate that participating families decreased the total number of calories and calories per dollar purchased from baseline to post-education (median total calories: baseline, 20,191; post-education, 15,991, p=0.008); median calories per dollar: baseline, 404; post-education, 320, p=0.008). The median grams of carbohydrates per dollar (baseline, 66, post-education, 45) and median calories from processed food (baseline, 11,000, post-education, 7845) were not reduced (p=0.06).

CONCLUSIONS

This pilot study demonstrated that grocery shopping practices are an important factor to address in nutrition education among Spanish-speaking, low-income individuals, and that there may be ways to encourage low-income, Latino families to purchase healthier foods. Findings challenged arguments suggesting that such an approach is not possible because of the high cost of healthier foods.

How accurate are parental responses concerning their fourth-grade children's school-meal participation, and what is the relationship between children's body mass index and school-meal participation based on parental responses?

BACKGROUND

This article investigated (1) parental response accuracy of fourth-grade children's school-meal participation and whether accuracy differed by children's body mass index (BMI), sex, and race, and (2) the relationship between BMI and school-meal participation (based on parental responses).

METHODS

Data were from four cross-sectional studies conducted from fall 1999 to spring 2003 with fourth-grade children from 13 schools total. Consent forms asked parents to report children's usual school-meal participation. As two studies' consent forms did not ask about lunch participation, complete data were available for breakfast on 1,496 children (51% Black; 49% boys) and for lunch on 785 children (46% Black; 48% boys). Researchers compiled nametag records (during meal observations) of meal participation on randomly selected days during children's fourth-grade school year for breakfast (average nametag days across studies: 7-35) and for lunch (average nametag days across studies: 4-10) and categorized participation as "usually" (≥ 50% of days) or "not usually" (< 50% of days). Weight and height were measured. Concerning parental response accuracy, marginal regression was used with agreement between parental responses and nametag records as the dependent variable; independent variables were BMI, age, sex, race, and study. Concerning a relationship between BMI and school-meal participation, marginal regression was used with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, age, sex, race, and study.

RESULTS

Concerning breakfast participation and lunch participation, 74% and 92% of parents provided accurate responses, respectively. Parental response accuracy was better for older children for breakfast and lunch participation, and for Black than White children for lunch participation. Usual school-meal participation was significantly related to children's BMI but in opposite directions -- positively for breakfast and inversely for lunch.

CONCLUSIONS

Parental response accuracy of children's school-meal participation was moderately high; however, disparate effects for children's age and race warrant caution when relying on parental responses. The BMI results, which showed a relationship between school-meal participation (based on parental responses) and childhood obesity, conflict with results from a recent article that used data from the same four studies and found no significant relationship when participation was based on nametag records compiled for meal observations.

Nonsignificant relationship between participation in school-provided meals and body mass index during the fourth-grade school year

Data from four cross-sectional studies involving fourth-grade children were analyzed to investigate the relationship between participation in school-provided meals and body mass index (BMI), and the effect observed energy intake has on that relationship. Participation and BMI data were available on 1,535 children (51% black; 51% girls) for 4 school years (fall 1999 to spring 2003; one study per school year) at 13 schools total. Direct meal observations were available for a subset of 342 children (54% black; 50% girls) for one to three breakfasts and one to three lunches per child for a total of 1,264 school meals (50% breakfast). Participation in breakfast, lunch, and combined (both meals on the same day) was determined from nametag records compiled for meal observations for each study. Weight and height were measured. A marginal regression model was fit with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, combined participation, sex, age, race, and study. For the subset of children, observed energy intake at breakfast, lunch, and combined was included in additional analyses. Participation in breakfast, lunch, and combined was not significantly associated with BMI regardless of whether analyses included observed energy intake (P values >0.181). The relationship between observed energy intake at breakfast and lunch, separately and combined, with BMI was positive (P values <0.01). In conclusion, these results do not support a relationship between school-meal participation and BMI but do support a relationship between observed energy intake at school meals and BMI during fourth grade.

Household food security and fruit and vegetable intake among low-income fourth-graders

OBJECTIVE

To examine the relationship between household food security and children's and parents' fruit, vegetable, and breakfast consumption and fruit and vegetable availability.

DESIGN

Cross-sectional study using matched parent-child surveys.

SETTING

Title I elementary schools in Maryland.

PARTICIPANTS

Ninety-two low-income parent-child dyads recruited from fourth-grade nutrition education programs completing a baseline evaluation.

MAIN OUTCOME MEASURES

Fruit and vegetable intake, breakfast consumption, and fruit and vegetable availability in home and school.

ANALYSIS

Chi-square tests, 1-way ANOVA.

RESULTS

Thirty-six percent of parents reported low/very low household food security, and both parents and students reported low fruit and vegetable intake. Students from households with low food security who were not participating in school nutrition programs had the lowest vegetable consumption and the fewest number of days consuming breakfast, indicating a relatively greater need for enrollment than their peers.

CONCLUSIONS AND IMPLICATIONS

Few differences between children in food-secure and food-insecure households were observed, which underscores the need for research on food insecurity and children's eating behaviors. Examination of other factors influencing fruit and vegetable intake and improvements in food environments and programs are needed. Efforts to increase enrollment among eligible students in school nutrition programs may reduce negative consequences of household food insecurity.

Federal food policy and childhood obesity: a solution or part of the problem?

Amid growing concern about childhood obesity, the United States spends billions of dollars on food assistance: providing meals and subsidizing food purchases. We examine the relationship between food assistance and body mass index (BMI) for young, low-income children, who are a primary target population for federal food programs and for efforts to prevent childhood obesity. Our findings indicate that food assistance may unintentionally contribute to the childhood obesity problem in cities with high food prices. We also find that subsidized meals at school or day care are beneficial for children's weight status, and we argue that expanding access to subsidized meals may be the most effective tool to use in combating obesity in poor children.

The School Breakfast Program strengthens household food security among low-income households with elementary school children

The School Breakfast Program is an important component of the nutritional safety net and has been linked to positive changes in meal patterns and nutritional outcomes. By offering a breakfast, which for low-income children is available either at no cost or reduced price, the program also has the potential to increase household food security. This study examined the relationship between availability of the School Breakfast Program and household food security among low-income third-grade students by using data from the Early Childhood Longitudinal Survey-Kindergarten Cohort. The primary sample included 3010 students. Availability of school breakfast was assessed by surveys of school administrators. Food security was assessed by parents' reports by using the standard 18-item food security scale and considering 2 different food security thresholds. A probit model was estimated to measure the relationship between school breakfast availability and household food security while controlling for a range of other characteristics. Access to school breakfast reduced the risk of marginal food insecurity but not the risk of food insecurity at the standard threshold. That is, the program appeared beneficial in offsetting food-related concerns among at-risk families, although not necessarily in alleviating food insecurity once hardships had crossed the food insecurity threshold. Increasing the availability of school breakfast may be an effective strategy to maintain food security among low-income households with elementary school children.

Food insecurity and weight status among U.S. children and families: a review of the literature

CONTEXT

Food insecurity disproportionately affects U.S. demographic groups of children and adult family members at the highest risk for obesity and may lead to weight gain through various pathways. This article reviews research regarding the relationship between food insecurity and weight status, and the potential role of federal food and nutrition assistance programs.

EVIDENCE ACQUISITION

A search for relevant peer-reviewed research studies among U.S. children and nonelderly adults, published between 2000 and March 2010, identified 42 studies regarding the relationship between food insecurity and weight status. There were 22 studies regarding the potential role of food and nutrition assistance programs.

EVIDENCE SYNTHESIS

Among children and men, support for an association between food insecurity and weight status has been mixed. Women who experience food insecurity are more likely to be overweight or obese compared to women with adequate household resources for food; however, there is little evidence that food insecurity promotes increased weight gain over time. Long-term participation in the Supplemental Nutrition Assistance Program may increase risk for excess weight gain.

CONCLUSIONS

Additional research addressing the limitations of current studies is needed to fully understand the observed linkages between food insecurity and risk for obesity. Nevertheless, there is substantial evidence these nutritional problems coexist, and it is critical that future efforts to eliminate hunger consider opportunities to promote healthy food choices and physical activity. Evaluations of policy changes and other intervention strategies are needed to determine the potential for food and nutrition assistance programs to more effectively reduce obesity among participants.

Associations between the home and school environments and child body mass index

This paper examined associations between various aspects of home and school environments and child body mass index (BMI) in the Early Childhood Longitudinal Study - Kindergarten cohort, a panel dataset of US children collected from 1998 to 2004. Using three-level growth curve modeling with a sample of approximately 11,400 children, it assessed whether these aspects were related to initial BMI and to the rate of growth of BMI over the period from kindergarten to fifth grade, independent of a large number of controls. A number of home and school factors were associated with initial BMI and the growth of BMI. Greater hours of sleep by children, more lunches eaten at school, and the adequacy of their school cafeterias and the adequacy of their school gymnasiums were all significantly associated with lower initial levels of BMI. More breakfasts typically eaten per week with their families and greater minutes of recess (free time for activity at school) were each associated with decreases in the rate of BMI growth over time, while more television watched, greater average hours of weekly maternal employment, more school lunches and school breakfasts eaten, and the adequacy of children's gymnasiums were associated with faster rates of BMI growth over the study period. The study adds to the existing literature on environmental influences on child BMI by illustrating the utility and necessity of examining multiple influences within a single analytic framework. Further research and policy efforts should continue to acknowledge the multi-etiological manner by which the environment can affect rates of child obesity.

Predictors of obesity in school-aged Jordanian adolescents

This cross-sectional study aimed to estimate the frequency of overweight and obesity in adolescents as defined by the International Obesity Task Force, and to estimate the effect of sociodemographic and health behaviours (eating habits and physical activity) that predict obesity. A stratified (by gender) random sample of 518 adolescents, aged 15 or 16 years was obtained from eight public schools in Amman. In this sample 17.5% were overweight and 9.6% were obese. The predictors of obesity and overweight (excess weight) were: (i) fathers attained primary and secondary education; (ii) total monthly family income > or = 300 (JD); (iii) working mothers; (iv) family size < or = 6; and (v) having obese parents. Eating a low quality diet (chips, candy) was a significant dietary predictor of excess weight. The family variables found to be important predictors along with a low quality diet suggest that family interventions would be necessary in the control of adolescent excess weight.

Children's body mass index, participation in school meals, and observed energy intake at school meals

BACKGROUND

Data from a dietary-reporting validation study with fourth-grade children were analyzed to investigate a possible relationship of body mass index (BMI) with daily participation in school meals and observed energy intake at school meals, and whether the relationships differed by breakfast location (classroom; cafeteria).

METHODS

Data were collected in 17, 17, and 8 schools during three school years. For the three years, six, six, and seven of the schools had breakfast in the classroom; all other schools had breakfast in the cafeteria. Information about 180 days of school breakfast and school lunch participation during fourth grade for each of 1,571 children (90% Black; 53% girls) was available in electronic administrative records from the school district. Children were weighed and measured, and BMI was calculated. Each of a subset of 465 children (95% Black; 49% girls) was observed eating school breakfast and school lunch on the same day. Mixed-effects regression was conducted with BMI as the dependent variable and school as the random effect; independent variables were breakfast participation, lunch participation, combined participation (breakfast and lunch on the same day), average observed energy intake for breakfast, average observed energy intake for lunch, sex, age, breakfast location, and school year. Analyses were repeated for BMI category (underweight/healthy weight; overweight; obese; severely obese) using pooled ordered logistic regression models that excluded sex and age.

RESULTS

Breakfast participation, lunch participation, and combined participation were not significantly associated with BMI or BMI category irrespective of whether the model included observed energy intake at school meals. Observed energy intake at school meals was significantly and positively associated with BMI and BMI category. For the total sample and subset, breakfast location was significantly associated with BMI; average BMI was larger for children with breakfast in the classroom than in the cafeteria. Significantly more kilocalories were observed eaten at breakfast in the classroom than in the cafeteria.

CONCLUSIONS

For fourth-grade children, results provide evidence of a positive relationship between BMI and observed energy intake at school meals, and between BMI and school breakfast in the classroom; however, BMI and participation in school meals were not significantly associated.

Do working mothers raise couch potato kids? Maternal employment and children's lifestyle behaviours and weight in early childhood

Alarm about the increasing prevalence of childhood obesity has focussed attention on individual lifestyle behaviours that may contribute to unhealthy weight. More distal predictors such as maternal employment may also be implicated since working mothers have less time to supervise children's daily activities. The research reported here used two waves of data from the Longitudinal Study of Australian Children to investigate whether mothers' hours in paid work shape young children's television viewing, snacking and physical activity, and through those lifestyle behaviours, children's weight at ages 4-5 years and 6-7 years. At both ages, children's lifestyle behaviours were interrelated and associated with weight status. Cross-sectional analysis confirmed small, direct associations between longer hours of maternal employment and child weight at age 4-5 years, but not with child's weight measured two years later. In both the cross-sectional and prospective analyses, the children of mothers who worked part-time watched less television and were less likely to be overweight than children of mothers who were not employed or who worked full-time. While associations were small, they remained significant after adjustment for maternal weight, household income and other factors. The combination of direct and indirect relationships between mothers' work hours and the weight status of their young children provides additional support to calls for family-friendly work policies as an important means for promoting healthy family lifestyles and early childhood wellbeing.

Participation in the School Breakfast Program: new evidence from the ECLS-K

This article examines determinants of participation in the federal School Breakfast Program among third-grade public school students. Data come from the Early Childhood Longitudinal Study—Kindergarten Cohort. Results suggest that participation is much less common in the School Breakfast Program than in the National School Lunch Program, even among children whose schools offer both programs. Economic vulnerability, time constraints, and local norms are found to be linked to participation; program and logistical aspects, such as whether schools serve breakfast in the classroom and the length of time available for breakfast, are predictive. Results suggest that participation in the School Breakfast Program could be increased by adjusting program characteristics and by enhancing outreach efforts.

The effects of the National School Lunch Program on education and health

This paper estimates the effects of participating in the National School Lunch Program in the middle of the 20th century on adult health outcomes and educational attainment. I utilize an instrumental variables strategy that exploits a change in the formula used by the federal government to allocate funding to the states. Identification is achieved by the fact that different birth cohorts were exposed to different degrees to the original formula and the new formula, along with the fact that the change of the formula affected states differentially by per capita income. Participation in the program as a child appears to have few long-run effects on health, but the effects on educational attainment are sizable. These results may suggest that subsidized lunches induced children to attend school but displaced food consumption from other sources. Alternatively, the program may have had short-run health effects that dissipated over time but that facilitated higher educational attainment.

Participation in the national school lunch program: importance of school-level and neighborhood contextual factors

BACKGROUND

This study examined the effect of stigma (proxied by school-level peer participation), neighborhood food environment, and demographic characteristics on participation in the U.S. Department of Agriculture National School Lunch Program (NSLP).

METHODS

The 1997 and 2003 waves of the Child Development Supplement to the Panel Study of Income Dynamics were linked to external data on school-level free lunch eligibility rate, fast food restaurant availability in the school zip code, and food store availability and neighborhood socioeconomic status in the home zip code. Probit models examined the effects of contextual and demographic factors on NSLP participation and free/reduced-price NSLP participation, conditional on eligibility. Differences were analyzed by grade.

RESULTS

A 10% higher free lunch eligibility rate in a child's school was associated with a 1.8 percentage point increase in the probability of NSLP participation and 2.6 and 6.7 percentage points increase in free/reduced-price NSLP participation among all and high school eligible student, respectively. Fewer grocery stores and more convenience stores increased NSLP participation. Fast food restaurant availability in the school neighborhood decreased free/reduced-price NSLP participation for high school students only. The addition of the contextual factors reduced the estimated association with several of the demographic covariates, especially race.

CONCLUSIONS

The significant positive association between NLSP participation and school-level free lunch eligibility, especially for the free/reduced-price NSLP participation, suggested that stigma, or possibly peers, affected participation. Neighborhood and school contextual variables had significant effects on school lunch take-up and the results differed between high school and elementary/middle school students.

Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants

BACKGROUND

Access to foods and beverages on school campuses, at home, and other locations affects children's diet quality, energy intake, and risk of obesity.

OBJECTIVES

To describe patterns of consumption of "empty calories"--low-nutrient, energy-dense foods, including sugar-sweetened beverages--by eating location among National School Lunch Program (NSLP) participants and nonparticipants.

DESIGN

Cross-sectional study using 24-hour dietary recall data from the 2004-2005 third School Nutrition Dietary Assessment Study.

SUBJECTS/SETTING

A nationally representative sample of 2,314 children in grades one through 12, including 1,386 NSLP participants.

STATISTICAL ANALYSES PERFORMED

Comparisons, using t tests, of the proportion of children consuming low-nutrient, energy-dense foods and beverages, mean daily energy and energy from low-nutrient, energy-dense foods, and energy density by NSLP participation status.

RESULTS

On a typical school day, children consumed 527 "empty calories" during a 24-hour period. Eating at home provided the highest mean amount of energy from low-nutrient, energy-dense foods (276 kcal vs 174 kcal at school and 78 kcal at other locations). NSLP participants consumed less energy from sugar-sweetened beverages at school than nonparticipants (11 kcal vs 39 kcal in elementary schools and 45 kcal vs 61 kcal in secondary schools, P<0.01), but more energy from low-nutrient, energy-dense solid foods such as french fries and higher-fat baked goods in secondary schools (157 kcal vs 127 kcal, P<0.01). Participants were not more likely to consume sugar-sweetened beverages or low-nutrient, energy-dense foods at home or other locations. School lunch participants' consumption at school was less energy-dense than nonparticipants' consumption at school (P<0.01). Energy density was highest for consumption at locations away from home and school.

CONCLUSIONS

Improving home eating behaviors, where the largest proportion of total daily and energy from low-nutrient, energy-dense foods are consumed (especially from sugar-sweetened beverages, chips, and baked goods) is warranted. At schools, consumption of energy from low-nutrient, energy-dense foods may be reduced by limiting access to competitive foods and beverages, enforcing strong school wellness policies, and minimizing the frequency of offering french fries and similar potato products and higher-fat baked goods in school meals or à la carte.

Overweight children: assessing the contribution of the built environment

OBJECTIVE

To examine the relationship between the built environment and overweight status in children.

METHODS

Analyses were based on 2482 children aged 5-18 and their primary care givers who participated in the second wave of the Child Development Supplement (CDS-II) of the Panel Study of Income Dynamics (PSID). CDS-II is a nationally representative survey that was administered in October 2002-May 2003. A number of built environment characteristics were examined: population density, alpha index of connectivity, urban design, pedestrian fatality from motor vehicle crashes, restaurant density, and grocery store and convenience store densities. Also, interviewer's observations on neighborhood physical disorder, such as the condition and upkeep of the buildings and street surface on the block were analyzed.

RESULTS

Living in a neighborhood with higher convenience store density (OR=1.3, p<0.05) and living in a neighborhood built after 1969 (OR=1.9, p<0.01) is associated with a higher probability of being overweight for children and adolescents. Living in the neighborhood where no physical disorder (OR=0.5, p<0.01) is observed is associated with a decreased likelihood of being overweight.

CONCLUSIONS

The results of this study emphasize a particular importance of the built environment of the neighborhood for weight status of children and adolescents.

Family food insufficiency is related to overweight among preschoolers’

This paper studies the relationship between family food insufficiency and being overweight in a population-based cohort of preschool children (n=2103) using data from the Longitudinal Study of Child Development in Québec (1998-2002) (LSCDQ). Family food insufficiency status was derived when children were 1.5 years of age (from birth to 1.5 years) and at 4.5 years of age (from 3.5 to 4.5 years). Children's height and weight were measured at home at 4.5 years. Overweight was defined according to the US CDC sex- and age-specific growth charts and Cole's criteria. Statistical analyses were done with SAS (version 8.2). In multivariate analyses, mean body mass index (BMI) was higher for children from food insufficient families compared to children from food sufficient families, even when important factors associated with BMI, such as child's birth weight, parental BMI, maternal education, and family income sufficiency were considered. We did not report any gender effects in the multivariate analyses. The presence of family food insufficiency at some point during preschool years more than tripled (OR 3.4, 95% CI 1.5-7.6) the odds for obesity using the Cole criteria, and doubled (OR 2.0, 95% CI 1.1-3.6) the odds for overweight at 4.5 years using the CDC growth curves indicator. We observed an interaction between birth weight and family food insufficiency in relation to being overweight at 4.5 years. Low-birth-weight children living in a household that experienced food insufficiency during preschool years are at higher risk of overweight at 4.5 years. Given this important finding, supportive interventions targeting low-income and food insufficient families, including pregnant women, are recommended for preventing overweight and obesity among their children.